Provider Demographics
NPI:1740543990
Name:TIVA OBA, L.L.C.
Entity type:Organization
Organization Name:TIVA OBA, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, APRN
Authorized Official - Phone:502-797-1567
Mailing Address - Street 1:4729 RAZOR CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-5533
Mailing Address - Country:US
Mailing Address - Phone:502-797-1567
Mailing Address - Fax:502-713-1979
Practice Address - Street 1:4729 RAZOR CREEK WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-5533
Practice Address - Country:US
Practice Address - Phone:502-797-1567
Practice Address - Fax:502-713-1979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005577367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100080880Medicaid
IN201012810Medicare PIN
KY7100080880Medicaid